Clinical symptoms and psychological changes of patients with COVID-19 in Jiangxi Province

Objective The purpose of this study was to determine the prevalence and differences in etiology, clinical manifestations, and psychological activity of coronavirus disease-19 (COVID-19) among patients. Results We recruited 90 subjects, 30 were healthy controls, 30 were patients with moderate infection, and 30 were patients with severe/critical infections. No significant differences were noted in the sex ratio, mean age, body mass index, or blood type; however, the history of exposure of the patients with COVID-19 compared with healthy controls was noteworthy. The erythrocyte sedimentation rate, as well as the levels of C-reactive protein and serum amyloid A (SAA) were all increased. In terms of mental health, there were significant differences in the worry scores between severely and moderately infected patients and healthy controls. There was a significant difference in depression scores between patients with moderate infection and healthy hypertension, and there was also a significant difference in dream worry scores. Analysis of the Mini-Mental State Examination scores showed that for patients with moderate infection, the depression score was moderately and positively correlated with the dream anxiety score. For patients with severe infection, the anxiety score was positively correlated with the dream anxiety score, and the depression score was moderately and positively correlated with the dream anxiety score. informed The body mass index (BMI), contact history, incubation period, temperature, pulse, respiratory rate, systolic blood pressure, diastolic blood pressure, and other clinical data were recorded. Laboratory tests, including routine blood tests, as well as those to determine erythrocyte sedimentation, C-reactive protein, calcitonin, myocardial enzymes, liver and kidney function, electrolytes, coagulation


Clinical symptoms and psychological changes of patients with COVID-19 in Jiangxi Province
China, 61,475 cured cases (76.10%), and 3,158 deaths (3.91%). 1 All 31 provinces in mainland China have adopted first-level responses to major public health emergencies. The central government and some provincial governments have provided food and medicine, and have sent expert and medical teams to manage and control the most affected areas (outbreak response in Wuhan and surrounding cities in Hubei Province). On February 24, 2020, Chinese members of parliament began to consider a draft decision to completely ban the illegal wildlife trade and eliminate the undesirable habit of the consumption of wild animals to protect public health. 1 On January 12, 2020, the World Health Organization (WHO) temporarily named the new virus "2019-New Coronavirus (2019-nCoV)." 2 Subsequent research confirmed that 2019-nCoV belongs to a new type of β-coronavirus, because its genetic characteristics differed significantly from those of the severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle Eastern respiratory syndrome coronavirus (MERS-CoV). Furthermore, its homology with bat-sl-covzc45 exceeded 85%; 3 thus, the WHO renamed it to the "severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)." 4 Prior to this, six coronaviruses were known to cause human disease, including alpha 229E and NL63, HKU1, OC43, SARS-CoV, and beta MERS-CoV. In normal individuals, 229E, NL63, HKU1, and OC43 only causes common cold symptoms, while severe SARS-CoV and MERS-CoV can cause death. 5 The new coronavirus is highly contagious and can be transmitted from person to person through respiratory droplets or contact. The general population is susceptible. Epidemiological investigation shows that the incubation period of the new coronavirus pneumonia is generally 3-7 days, and the longest incubation does not exceed 14 days. 8 It differs from SRAS-CoV, as COVID-19 is also contagious during the incubation period. 9 In addition, interpersonal transmission can occur both in hospitals and in the home environment. 10 COVID-19 outbreaks have occurred in many cities in China, and have expanded globally, including South Korea and Japan, among other countries. This has led the WHO to announce a Public Health Emergency of International Concern (PHEIC). 11 After analyzing the diagnosis and treatment experience of cured patients, we concluded that early identification, reporting, isolation, diagnosis, and treatment constitute some of the best and most effective ways to curb pneumonia caused by SARS-CoV-2. 12 At the same time, the efficacy of traditional Chinese and western medicine has been recognized. Nationally, more than 75% of patients with COVID-19 in Hubei have been receiving traditional Chinese medicine treatment, compared with more than 90% in other parts of China. 12 Thus far, despite new coronavirus outbreaks, China has launched public health emergency interventions for mental health, such as the establishment of a mental health hotline and the establishment of nationwide telephone and internet-based counseling services to facilitate patient knowledge, alleviate fears, and solve problems related to mental health. 12 The National Health Commission has even issued guidelines for local authorities to promote psychological crisis interventions for patients, medical staff, and people under medical observation. 13 However, the type of influence the patient's mental health status or mental state may have on the course of the disease, and the extent to which it may be affected remains unknown. To our knowledge, no scientific study has been conducted to analyze the relationship between the mental health of the patient and the course of the disease. Therefore, we aimed to use the Hospital Anxiety and Depression Scale (HADS), Mini-Mental State Examination (MMSE), and Van Dream Anxiety Scales, which are common clinical assessments to determine anxiety, depression, and the mental state. We also predict and analyze health status, mental health status of patients with moderate and severe infections, to understand the correlation between mental status and disease severity. In addition, we performed statistical analysis of the epidemiological data, clinical signs, as well as the imaging and laboratory test results of patients to provide timely frontline information.

Subjects and study design
A total of 60 patients with COVID-19 were admitted to the First Affiliated Hospital of Nanchang University from January 27 to February 10, 2020, including 30 patients with moderate infection and 30 patients with severe infection (21 patients with severe infection and nine critical patients). We collected epidemiological and clinical data of the patients after admission, and performed laboratory tests, such as routine blood tests, and those to determine erythrocyte sedimentation, C-reactive protein, calcitonin, myocardial enzymes, liver and kidney function, electrolytes, coagulation function, T cell subsets, and immune indicators, among others. Chest computed tomography (CT) scans were also acquired.

Data collection
Prior to participating in the study, all subjects or their families voluntarily gave written informed consent. Through adequate medical history taking and detailed physical examination, we obtained the age and weight of 60 patients with COVID-19, admitted to the First Affiliated Hospital of Nanchang University from January 27 to February 10, 2020. We also recruited 30 healthy controls.
The body mass index (BMI), contact history, incubation period, temperature, pulse, respiratory rate, systolic blood pressure, diastolic blood pressure, and other clinical data were recorded. Laboratory tests, including routine blood tests, as well as those to determine erythrocyte sedimentation, Creactive protein, calcitonin, myocardial enzymes, liver and kidney function, electrolytes, coagulation function, and T cell subsets were performed, and chest CT scans were obtained. According to the clinical classification method of "New Coronavirus Infected Pneumonia Diagnosis and Treatment Scheme (Trial Version 4)," 60 patients were divided into two groups; 30 patients with moderate infection and 30 patients with severe infection (including 21 patients with severe infection and nine critical patients).
We asked all 90 subjects to complete three scales (the HADS, MMSE scale, and the Van Dream Anxiety Scale). The HADS self-assessment scale is a reliable tool used for the detection of depression and anxiety in hospital outpatients. Thus, it can provide data on the severity of anxiety and depression. The MMSE scale is easy to implement and is widely used locally and abroad. It includes the following elements: time-oriented power, position-oriented power, instant memory, attention and computing power, delayed memory, language, and visual space. The Van Dream Anxiety Scale, as a subjective measure of anxiety during nightmares, can re-verify the true degree of anxiety to a certain extent.
The above three scales were applicable for the assessment of the psychological status and mental state of patients with COVID-19. By comparing and analyzing the HADS, MMSE, and Van Dream Anxiety Scale scores of the three groups of subjects, we were able to determine their mental health status, and identify any relationships between mental health and severity of the disease.

Statistical analyses
One-way analysis of variance (one-way ANOVA) in the SPSS® (SPSS Inc., Chicago, IL, USA) statistical analysis computer package version 17.0 was used to analyze the basic clinical characteristics (including sex, age, and BMI) of patients with moderate infection and those with severe infection, as well as the scale scores (such as anxiety score and depression score).
In addition, the chi-squared test and t-test were used to evaluate clinical symptoms and physical examination data, such as the incubation period, course of disease, pulmonary CT lesions, and body temperature in patients with moderate infection and those with severe infection. Further analysis was conducted on the results of laboratory tests of immune indicators, including routine blood tests, tests of erythrocyte sedimentation, C-reactive protein, calcitonin, myocardial enzymes, liver and kidney function, electrolytes, coagulation function, and T cell subsets in the patients with moderate infection and those with severe infection to determine the any differences between the two groups. A P-value of < 0.05 was considered statistically significant.

Comparison of chest CT images between healthy controls and patients with COVID-19
We found no lung lesions in the healthy controls, while the number of lung lesions in patients with COVID-19 was 2.68 ± 1.61. The CT images of the lungs in healthy controls and in patients with COVID-19 are shown in Fig. 1. infection and nine critical patients). No significant differences were noted in sex ratio, mean age, BMI, or blood type (all P > 0.05). However, the history of exposure among the patients with COVID-19 compared with that of the healthy controls was noteworthy (P < 0.001).
Among both the patients with moderate infection and those with severe infection, the proportion of patients with blood type A in confirmed cases was higher. Patients with moderate infection and those with severe infection showed no significant differences in the incubation period (P = 0.577), disease period (P = 0.481), body temperature (P = 0.720), pulse (P = 0.658), respiration (P = 0.286), systolic blood pressure (P = 0.704), diastolic blood pressure (P = 0.564), or initial symptoms (P = 0.257).
However, the chest CT images were still able to facilitate comparisons among the lungs of ordinary patients, and those with moderate and severe infections. Furthermore, seven patients (11.67%) had complications related to chronic underlying diseases, such as hypertension, diabetes, and hepatitis B. Tables 1 and 2 show the detailed epidemiological data and   clinical symptoms of healthy controls, patients with moderate infection, and patients with severe infection. In addition, Fig. 2 shows the distribution of patients with severe infection among the study participants.    Table 3 details the results of laboratory tests. The mean ± standard deviation of anxiety scores reflecting the mental health of patients based on the HADS and Van Dream Anxiety Scale (presented in Table 1).
Regarding the mental health aspects, a significant difference was noted among the anxiety scores of patients with severe infection and healthy controls (P < 0.001), besides the significant difference between patients with moderate infection and healthy controls shows P = 0.004. The depression scores of patients with moderate infection differed significantly from those of healthy controls (P < 0.001). Analysis of the MMSE scores revealed that COVID-19 affects both patients with moderate infection and patients with severe infection.
As the patient's condition worsened, their anxiety score, depression score, and dream anxiety score increased (Fig. 3), but the MMSE score gradually decreased (Fig. 5). Figure 4 shows the positive ratio of HADS scores in healthy controls, patients with moderate infection, and patients with severe infection. We classified the HADS scores greater than 8 as abnormal, that is, anxiety or depression was positive. An obvious difference was noted in the positive rate among healthy controls, and patients with moderate or severe infection.

Discussion
Although the nucleic acid sequence and gene characteristics of SARS-CoV-2 differ from those of SARS coronavirus and MERS coronavirus, they are similar to some beta coronaviruses from bats and have a homology of more than 85% with BAT-sl-covzc45. 3 When the virus is isolated from patients' lung fluid, blood, and nasal polyp sub-samples, it has shown typical coronavirus characteristics under electron microscopy. Furthermore, its transformation into SARS-CoV-2 is a characteristic of the new beta genera, which includes features such as capsules, round or oval particles that are often polymorphic, and 60-140 nm in diameter. 3 In a recent study, SARS-CoV-2 and SARS-CoV were shown to share the angiotensin-converting enzyme 2 (ACE2) receptor. 14 Furthermore, tissues with ACE2 expression may become target organs of SARS-CoV-2. 14 The spike glycoprotein (S protein) on the surface of SARS-CoV mediates receptor recognition and membrane fusion. 15 The S1 subunit contains the binding domain (RBD) of the receptor that binds directly to ACE2. 16 Moreover, SARS-CoV-2 has the same S protein as SARS; thus, SARS-CoV-2 may use ACE2 to infect. 17 Surprisingly, a recent bioRxiv preprint shows that the affinity between ACE2 and the RBD of SARS-CoV-2 is 10-20 times higher than that between ACE2 and the RBD of SARS-CoV. 18 Therefore, the S protein largely determines host specificity and infectivity of the new coronavirus, and is also a key target for the development of vaccines and therapeutic antibodies, and clinical diagnosis. Currently, exploration of the important prognostic factors and therapeutic drugs for COVID-19 is a matter of urgent concern. On February 10, 2020, after comparing the clinical characteristics, imaging characteristics, and treatment methods of patients with mild, moderate, and severe infections, an expert team at the Beijing Ditan Hospital concluded that the neutrophil-to-lymphocyte ratio (NLR) may be an influential factor in the prognosis and early identification of patients with severe infection.
Patients over 50 years of age with an NLR ≥ 3.13 constitute a high-risk group prone to severe infections and should be admitted to the ICU immediately, if necessary. 22 Previously, Holshue et al. 23 found that remdesivir was an effective drug used during the diagnosis and treatment of the first COVID-19 patient in the United States. Although remdesivir has not been licensed or approved for use in mainland China, a phase II clinical study of the drug, confirms that long-term use of remdesivir is safe. 24 As a designated hospital for the treatment of patients with severe COVID-19 infection in the Jiangxi Province, our hospital has had a concentration of most of the severe cases within the province. targeted psychological interventions to alleviate the patient's psychological burden will likely provide novel ideas for clinical treatment and may be of practical significance.

Limitations
This study was affected by the following limitations: only 60 patients were included in the study (30 patients with moderate infection, 21 patients with severe infection, and nine critical patients). A large number of confirmed patients were continuously being admitted to the hospital during analysis of the data. Therefore, the researchers only obtained data from patients diagnosed with the infection in some laboratories within Jiangxi Province during the study period.
Secondly, because the patients were selected specifically from Jiangxi Province, which included five cities, the results obtained were from a single study center. Furthermore, most patients were not discharged when the analysis of the data was completed. Thus, it was not possible to estimate mortality and cure rates, among other factors.

Conclusion
The history of exposure and abnormalities on chest CT scans showed considerable diagnostic value.
Patients with severe infection had more pain and sputum in the throat area than patients with moderate infection. Patients with blood type A might be more susceptible to COVID-19, and lymphopenia indicated worsening of COVID-19. In patients with moderate infection and those with severe infection, the depression score and dream anxiety score were moderately and positively correlated. In patients with severe infection, the anxiety score and dream anxiety score were also moderately and positively correlated.
List Of Abbreviations CYZ, WZ, and JZ conceived and designed the present study. XPL, FX and YS were responsible for acquiring the data, designing the figures and tables and drafting the manuscript. MHZ, JJY contributed to the acquisition of the data and interpreting the results. FL assisted in the acquisition of the data and drafting the manuscript. WZ, SGX assisted in the acquisition and analysis of the data with constructive discussion.  severe and 9 critical patients), 19 were from Nanchang, 4 were from Fuzhou, 4 were from Xinyu, 2 were from Jiujiang, and 1 was from Ji'an. Note: The designations employed and the presentation of the material on this map do not imply the expression of any opinion whatsoever on the part of Research Square concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. This map has been provided by the authors. Mental health assessments for Health controls, common and severe patients. Notes: Anxiety scores and depression scores were obtained from HADS, and dream anxiety scores were obtained from the Van Dream Anxiety Scale. * indicates that the difference between the two groups is statistically significant. Abbreviations: HADS, the Hospital Anxiety and Depression Scale.